Lesson 5: Psychological therapies for SZ Flashcards
3 main psychological therapies
-cognitive behavioural therapy (CBT)
-family therapy
-token economies
CBT
-NICE recommend that all patients should be offered CBT
-originally developed to provide treatment for residual symptoms that persist despite the use of antipsychotic medication
-aims to help people establish links between their thoughts, feelings or actions and their symptoms and general level of functioning
-can be delivered in groups or on one to one basis, NICE recommend at least 16 sessions
-patients are encouraged to trace back to the origins of their symptoms in order to get a better idea of how they might have developed
-encouraged to evaluate the content of their delusions and consider ways to test the validity of their faulty beliefs
-the therapist lets the patient develop their own alternatives to these previous maladaptive beliefs, ideally by looking for alternative explanations and coping strategies that are already present in the patients mind
CBT process
-Assessment: the patient expresses their thoughts to the therapist, realistic goals for therapy are discussed using the patients current distress as motivation for change
-Engagement: the therapist empathises with the patients perspective and their feelings of distress, and stresses that explanations for their distress can be developed together
-ABC Model: patient gives their explanation of the activating events (A) that appear to cause their emotional and behavioural (B) consequences (C), patients own beliefs can then be rationalised, disputed and changed
-Normalisation: conveying to patients that many people have unusual experiences such as hallucinations and delusions under many circumstances reduces anxiety and a sense of isolation, the patient feels less alienated and stigmatised and possibility of recovery seems more likely
-Critical Collaborative Analysis: therapist uses gentle questioning to help the patient understand illogical deductions and conclusions, questioning can be carried out without causing distress provided there is an atmosphere of trust between the patient and the therapist who remains empathetic and non-judgemental
-Developing Alternative Explanations: the patient develops their own alternative explanations for their previously unhealthy assumptions, if the patient is not forthcoming with healthy alternative explanations new ideas can be constructed in cooperation with the therapist
evaluation of CBT
-CBTp more effective in treating sz compared to medication alone, NICE 2024 review of sz treatments found consistent evidence, reduced hospitalisation rates up to 18 months following end of treatment, reduced severity of symptoms, improved social functioning, BUT difficult to assess as treated alongside medication
-effective depending on stage of disorder, Addington and Addington 2005 claim that in initial accute phase of sz self reflection is not appropriate but following stabilisation of psychotic symptoms with medication patients can benefit from group based CBTp, normalises experience by meeting others, individuals with more experience and greater realisation of problems most likely to benefit from CBTp
-estimated in UK only 1 in 10 individuals with sz actually have access to CBTp, even lower in some areas, Haddock et al 2013 found in NW England only 13 of 187 (13%) offered CBTp, Freeman et al 2013 added of those who are a significant number refuse or fail to attend sessions
-problems with meta-analysis, quality of studies, some fail to use random allocation, assess patients subsequent assessment of symptoms and general functioning after treatment, Juni et al 2001 concluded clear evidence that the problems associated with methodologically weak trials translated into biased findings about effectiveness of CBTp, Wykes et al 2008 found the more rigorous the study the weaker the effect of CBTp
family therapy
-range of interventions aimed at the family of someone with sz
-NICE recommends family therapy should be offered to all individuals diagnosed with sz who are in contact/live with family members, high priority for those with persistent symptoms at high risk of relapse
-offered for 3-12 months, at least 10 sessions, aimed at reducing the level of expressed emotion within family, Garety et al 2008 estimate relapse rates for individuals who receive family therapy as 25% compared to 50% for those receiving standard care
-involves providing family members with info about sz, finding ways to support individual and resolving practical problems
-reducing levels of expressed emotion and stress and increasing capacity of relatives to solve related problems, attempts to reduce incidence of relapse for person with sz
-commonly used in conjunction with drug treatment, individual is encouraged to talk to family and explain support they find helpful
family therapy processes
Psychoeducation- helping the person and carers understand and better deal with illness
Forming alliance with relatives/carer
Reducing emotional climate within family and burden of care
Enhancing relatives ability to anticipate and solve problems
Reducing expressions of anger and guilt by family members
Maintaining reasonable expectations among family members for patient performance
Encouraging relatives to set appropriate limits whilst maintaining some degree of spearation when needed
family therapy study
Pharoah et al 2010, reviewed 53 studies published between 2002-2010 to investigate effectiveness of family intervention, studies conducted Europe, asia, north america, compared outcomes from family therapy to standard care, concentrated on studies that were randomised controlled trials
FINDINGS
overall mixed, some reported improvement of mental state, others didnt
use of family therapy increased patient compliance with medication
appeared to show some improvement on general functioning but did not have much effect on concrete outcomes eg living independently/employment
reduction in risk of relapse and hospital admission during treatment and in 24 months after
family therapy evaluation
-mixed, increases patient compliance, suggests effectiveness but is it medication of family therapy that improves symptoms
-lack of blinding in family therapy studies, in Pharoahs 10 of 53 studies did not use any form of blinding, means raters were not blinded to condition participant was allocated, could create rater bias, may rate family therapy as showing improvements rather than those in control
-economical benefits, NICE review of family therapy studies demonstrated association with significant cost savings when offered in addition to standard care, reduction in costs of hospitalisation because of lower relapse rates, also reduces relapse rates for significant period after completion, cost savings are higher
-Lobban et al 2013 analysed results of 50 family therapy studies that included intervention to support relatives, 60% reported significant positive impact on at least one outcome category for relatives
but methodological quality was poor for most studies so diffficult to distinguish effective fron ineffective interventions
token economies
-reward systems used to manage the behaviour of patients with sz in hospital settings, in particular those who have developed maladaptive behaviours through spending too long in hospital with other patients that may have showed catatonia
-common for institutionalised patients to develop bad hygiene/pyjamas all day, changing these habits doesnt cure sz but improves likelihood they can live outside hospital setting
-based on principles of operant conditioning when patient is given a token(reward) for carrying out good behaviour(positive reinforcement), should encourage to repeat behaviour, then accumulated and swapped for tangible reward
-each patient assessed and given token for certain behaviours, given immediately to patients so can associate positive behaviour with reward as opposed to delayed rewards
-tokens are secondary reinforcers, as only have value once patient has learned they can be used to obtain rewards
token economy evaluation
-Dickerson et al 2005 reviewed 13 studies using token economies in treating sz, 11 reported beneficial effects directly attributable to token economy
however many had methodological issues which could have effected impact
-ethical concerns, clinicians may exercise control over important primary reinforcers such as food, privacy, access to activities
however, generally accpted certain basic rights that shouldnt be violated regardless of consequences
-lacks ecological validity, Corrigan 1991argued problems with administering with outpatients who live in community, in hospital patients receive 24 hour care, given tokens straight away, but cant be applied in community/real world
-no real conclusive reliable evidence, very few randomised trials carried out, could be more prominent especially in hospital setting
however critics argue token economies used in hospitals to manage and control patients rather than treat symptoms
